Dysphagia (swallowing problems)

Dysphagia is the medical term for swallowing difficulties.

Introduction

Dysphagia is the medical term for swallowing difficulties.

Some people with dysphagia have problems swallowing certain foods or liquids, while others cannot swallow at all.

Other signs of dysphagia include:

  • coughing or choking when eating or drinking
  • bringing food back up, sometimes through the nose
  • a sensation that food is stuck in the throat or chest

Over time, dysphagia can also cause symptoms such as weight loss and repeated chest infections.

You should see your doctor if you have any degree of swallowing difficulties.

Why does dysphagia happen?

Dysphagia is usually caused by another health condition, such as:

Dysphagia can also occur in children as a result of a developmental or learning disability.

Read more about the causes of dysphagia.

How is dysphagia treated?

Treatment usually depends on the cause and type of dysphagia. The specific type of dysphagia you have can usually be diagnosed after your ability to swallow has been tested and your oesophagus has been examined.

Treatments for dysphagia include:

  • speech and language therapy to learn new swallowing techniques
  • changing the consistency of food and drinks to make them safer to swallow
  • alternative forms of feeding, such as tube feeding through the nose or stomach
  • treating the narrowing of the oesophagus with surgery, by stretching or inserting a metal tube

Many cases of dysphagia can improve with treatment, but a cure is not always possible.

Read more about diagnosing dysphasia and treating dysphagia.

Complications

Dysphagia can sometimes lead to further problems.

One of the most common problems is coughing or choking, when food goes down the "wrong way" and blocks your airway.

If this happens often, then you may try to avoid eating and drinking due to a fear of choking. However, this can lead to malnutrition and dehydration.

Some people with dysphagia have a tendency to develop chest infections, such as aspiration pneumonia, which may require medical treatment.

Dysphagia can also affect your quality of life because it may prevent you from enjoying meals and social occasions.

Read more about the complications of dysphagia.

Causes

As swallowing is a complex process, there are many reasons why dysphagia can develop.

Some causes of dysphagia are explained below.

Neurological causes

The word neurological refers to the nervous system. This is made up of the brain, nerves and spinal cord.

Damage to the nervous system can interfere with the nerves responsible for starting and controlling swallowing. This can lead to dysphagia.

Some neurological causes of dysphagia include:

Congenital and developmental conditions

Congenital means something you are born with. Developmental conditions affect the way you develop.

Congenital or developmental conditions that may cause dysphagia include:

  • learning disabilities - where your child finds learning, understanding and communicating difficult
  • cerebral palsy - a group of neurological conditions that affect a child's movement and co-ordination
  • a cleft lip and palate - a common birth defect that results in a gap or split in the upper lip or the roof of the mouth

Obstruction

Health conditions that cause an obstruction in the throat or a narrowing of the oesophagus can make swallowing difficult. The oesophagus is the tube that carries food from the mouth to the stomach.

Some causes of obstruction and narrowing include:

  • mouth cancer](yourmd:/condition/cancer-of-the-mouth/introduction) or throat cancer, such as laryngeal cancer or [oesophageal cancer - once these cancers are treated, the obstruction may no longer be an issue
  • radiotherapy treatment, where doses of high-energy radiation are used to destroy cancer cells - it can cause scar tissue, which narrows the passageway in your throat and oesophagus
  • gastro-oesophageal reflux disease (GORD), a condition where stomach acid leaks back up into the oesophagus - the acid can cause scar tissue to develop, narrowing your oesophagus
  • infections, such as tuberculosis or thrush, which can lead to the inflammation of the oesophagus, known as oesophagitis

Muscular conditions

Any condition that affects the muscles used to push food down the oesophagus and into the stomach can cause dysphagia. However, such conditions are rare.

Two muscular conditions associated with dysphagia are:

  • scleroderma - where the immune system (the body’s natural defence system) attacks healthy tissue, leading to a stiffening of the throat and oesophagus muscles
  • achalasia - where muscles in the oesophagus become too stiff to allow food or liquid to enter the stomach

Other causes

As you get older, muscles used in swallowing can become weaker. This may explain why dysphagia is relatively common in elderly people. However, dysphagia should not simply be accepted as part of the ageing process and treatment is available to help people with age-related dysphagia.

Chronic obstructive pulmonary disease (COPD) is a collection of lung diseases that make it difficult to breathe in and out properly. Breathing difficulties can sometimes affect your ability to swallow.

Dysphagia may also develop as a complication of surgery to your head or neck.

Diagnosis

You should see your doctor if you are having any difficulty swallowing.

They will carry out an initial assessment and may refer you to another healthcare professional for further tests and treatment.

Tests will be carried out to determine whether your dysphagia is due to a problem with the mouth or throat (called oropharyngeal or high dysphagia), or the oesophagus (the tube that carries food from the mouth to the stomach, called oesophageal or low dysphagia).

A specific diagnosis can help make treatment more effective and reduce your chances of developing any complications of dysphagia, such as choking or pneumonia.

Recent medical history

Your doctor will want to know:

  • how long you have had dysphagia
  • whether your symptoms come and go or are getting worse
  • whether dysphagia has affected your ability to swallow solids, liquids or both
  • whether you have lost any weight

Referral to a specialist

Depending on the suspected cause of your dysphagia, your doctor may refer you for further tests with:

  • an ear, nose and throat (ENT) specialist
  • a speech and language therapist (SLT)
  • a neurologist - a specialist in treating conditions that affect the brain, nerves and spinal cord
  • a gastroenterologist - a specialist in treating conditions of the stomach and intestines
  • a geriatrician - a specialist in the care of elderly people

The type of tests you might need are explained below.

Water swallow test

A water swallow test can give a good initial assessment of your swallowing abilities. You will be given 150ml of water and asked to swallow it as quickly as possible. Your specialist will record how long it takes you to drink all the water and the number of swallows required.

You may also be asked to carry out a variation of the water swallow test that involves swallowing a soft piece of pudding or fruit.

A water swallow test is usually only carried out by speech and language therapists.

Barium swallow test

The barium swallow test, also called a barium meal test, is one of the most effective ways of assessing your swallowing ability and finding exactly where the problems are occurring. The test can often identify blockages or problems with the muscles used during swallowing.

As part of the test, you will be asked to drink barium solution. Barium is a non-toxic chemical widely used in tests because it shows up clearly on an X-ray. Once the barium moves down into your upper digestive system, a series of X-rays will be taken to identify any problems.

In some cases, this process will be recorded on video so that it can be studied in more detail. This is called a 'videofluoroscopy'.

If you need a barium swallow test, you will not be able to eat or drink for at least six hours before the procedure, so your stomach and duodenum (top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.

A barium swallow test usually takes about 15 minutes to perform. Afterwards you will be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system. You may feel slightly sick after the test, and the barium may cause constipation. Your stools may also be white for a few days afterwards as the barium passes through your system.

Manometry and 24 hour pH study

Manometry is a procedure to assess the function of your gullet (oesophagus). It involves passing a small tube (catheter) with pressure sensors through your nose into your gullet to monitor your gullet function.

The test measures the pressures within your gullet when you swallow. This can help determine how well the gullet is working.

The 24-hour pH study involves inserting a tube into your gullet through your nose to detect the presence of acid. The test measures the amount of acid that refluxes (flows back) from your stomach and can help determine the cause of any swallowing difficulties.

Diagnostic gastroscopy

Diagnostic gastroscopy is also known as diagnostic endoscopy of the stomach or OGD (which stands for oesophagogastroduodenoscopy). It is an internal examination using an endoscope. An endoscope is a long, thin, flexible tube that has a light source and a camera at one end.

The endoscope is passed down your throat and into your oesophagus. Images of the inside of your body are then shown on a television screen.

The endoscope can often detect cancerous growths or scar tissue caused by gastro-oesophageal reflux disease (GORD).

An endoscopy can also be used to provide treatment, such as stretching your oesophagus using a balloon or a bougie (thin, flexible medical instrument). The procedure can also be used to insert metal stents.

Read more about treating dysphagia.

Nutritional assessment

If dysphagia has affected your ability to eat, you may need a nutritional assessment to check that you are not lacking nutrients (malnourished). This could involve:

  • measuring your weight
  • calculating your [body mass index] (BMI) to check you are a healthy weight for your height
  • carrying out blood tests

Treatment

Most swallowing problems can be treated, although the treatment you receive will depend on the type of dysphagia you have.

Treatment will depend on whether the difficulty with swallowing occurs in the mouth or throat (called oropharyngeal or high dysphagia), or in the oesophagus (the tube that carries food from the mouth to the stomach, known as oesophageal or low dysphagia).

The cause of the dysphagia is also important when deciding on treatment. In some cases, treating the underlying cause, such as mouth cancer or oesophageal cancer, can help relieve swallowing problems.

Treatment for dysphagia may be delivered by a group of specialists called a multidisciplinary team (MDT). Your MDT may include a speech and language therapist, a surgeon and a dietitian, among others.

High (oropharyngeal) dysphagia

High dysphagia is where swallowing difficulties are caused by problems with the mouth or throat.

High dysphagia can be difficult to treat if the problems are due to a condition that affects the nervous system. This is because these problems cannot usually be corrected using medication or surgery.

There are three main treatment options for high dysphagia:

  • swallowing therapy
  • dietary changes
  • feeding tubes

These treatment options are described below.

Swallowing therapy

If you have high dysphagia, you may be referred to a speech and language therapist (SLT) for swallowing therapy. An SLT is a healthcare professional trained to work with people with feeding or swallowing difficulties.

SLTs use a range of techniques that can be tailored for your specific problem. For example, an SLT can help teach you swallowing exercises. Only use the techniques that your SLT teaches you, as not every technique will be suitable or effective.

Dietary changes

You may be referred to a dietitian for advice about changing your diet. A dietitian is a healthcare professional who specialises in nutrition. They can advise on dietary changes as well as ensuring you receive a healthy, balanced diet. An SLT can advise you about softer foods and thickened fluids that may be easier to eat and drink.

An SLT may also speak to members of your family or your carers to make sure you are getting the support you need at meal times. They may also try to increase your confidence with eating, for example by helping you overcome a fear of choking when you eat.

Feeding tubes

Feeding tubes can be used to provide nutrition while you are recovering your ability to swallow. They may also be required in severe cases of dysphagia that put you at risk of malnutrition and dehydration. Having a feeding tube can also make it easy for you to take the medication you may need for other conditions.

There are two types of feeding tubes:

  • a tube that is passed down your nose and into your stomach (nasogastric tubes)
  • a tube that is surgically implanted directly into your stomach (percutaneous endoscopic gastrostomy, or PEG, tubes)

Nasogastric tubes are designed for short-term use. The tube will need to be replaced and swapped to the other nostril after about a month. PEG tubes are designed for long-term use and last several months before they need to be replaced.

Most people with dysphagia prefer to use a PEG tube because the equipment can be easily hidden under clothing. However, PEG tubes carry a greater risk of complications compared to nasogastric tubes.

Minor complications of PEG tubes include:

  • tube displacement
  • skin infection
  • tube blockage
  • tube leakage

Major complications of PEG tubes include:

  • internal bleeding
  • infection

People who use PEG tubes may also find it more difficult to resume normal feeding compared with those who use nasogastric tubes. This may be because the convenience of PEG tubes means people who use them are less willing to carry out swallowing exercises and dietary changes compared to people who use nasogastric tubes.

Discuss the advantages and disadvantages of both feeding tubes with your treatment team.

Low (oesophageal) dysphagia

Low dysphagia is where swallowing difficulties are due to problems with the oesophagus.

Medication

Depending on the cause of low dysphagia, it may be possible to treat it with medication. For example, proton pump inhibitors (PPIs), which are used to treat indigestion, may improve symptoms caused by narrowing or scarring of the oesophagus.

Botulinum toxin

Botulinum toxin, sometimes marketed under the name botox, can be used to treat achalasia. This is a condition where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach.

Botulinum toxin is a powerful poison that is safe to use in very small doses. The toxin can be used to paralyse the overly stiff muscles that are preventing food from reaching the stomach. However, the effects only last for around six months.

Surgery

Other cases of low dysphagia can usually be treated with surgery.

Endoscopic dilatation

Endoscopic dilation is widely used to treat dysphagia caused by obstruction. It can also be carried out to stretch your oesophagus if it is scarred.

Endoscopic dilatation will be carried out during an internal examination of your oesophagus using an endoscopy, also known as OGD (which stands for oesophagogastroduodenoscopy).

During the procedure, the endoscope is passed down your throat and into your oesophagus. Images of the inside of your body are shown on a television screen. Using the image as guidance, a small balloon or a bougie (a thin, flexible medical instrument) is passed through the narrowed area of your oesophagus to widen it. If a balloon is used, it is inflated to gradually widen your oesophagus before being deflated and removed.

You may be given a mild sedative before the procedure to relax you. There is a small risk that the procedure could cause a tear or perforation to your oesophagus.

inserting a stent

If you have oesophageal cancer that cannot be removed by surgery, it is usually recommended that you have stent insertion instead of endoscopic dilatation. This is because if you have cancer, there is a higher risk of perforating your oesophagus if it is stretched.

Stent insertion involves inserting a metal mesh tube, called a stent, into your oesophagus. The procedure can be performed during OGD (see above) or under X-ray guidance.

After it is inserted, the stent gradually expands in the tumour. This creates a passage big enough to allow food to pass through your narrowed oesophagus. To keep the stent open without blockages, you will need to follow a particular diet. You will be advised about this, but it is likely to include soft food.

Congenital dysphagia

If your baby is born with difficulty swallowing, known as congenital dysphagia, their treatment will depend on the cause.

Dysphagia caused by cerebral palsy

Dysphagia caused by cerebral palsy can be treated with speech and language therapy (SLT) to teach your child how to swallow, adjusting the type of food they eat and using feeding tubes.

Cleft lip and palate

Cleft lip and palate is a facial birth defect that can cause dysphagia. It is usually treated with surgery.

Dysphagia caused by narrowing of the oesophagus

This may be treated with a type of surgery called dilatation to widen the oesophagus.

Dysphagia caused by gastro-oesophageal reflux disease (GORD)

Dysphagia caused by GORD can be treated by using special thickened feeds instead of your usual breast or formula milk, and sometimes with medication.

Complications

The main complication of dysphagia is coughing and choking, which can lead to pneumonia.

Coughing and choking

If you have dysphagia, there is a risk of food, drink or saliva going down the "wrong way". It can block your airway, making it difficult to breathe and causing you to cough or choke.

If you have dysphagia, you may also develop a fear of choking. However, it is important you don't avoid eating and drinking, as this can lead to dehydration and malnutrition.

If you often choke on your food due to dysphagia, then you may also be at an increased risk of developing a condition called aspiration pneumonia (see below).

Aspiration pneumonia

Aspiration pneumonia is a chest infection that can occur if you accidently inhale something, such as a small piece of food, which causes irritation in the lungs or damages them. Older people are at a particular risk of developing aspiration pneumonia.

The symptoms of aspiration pneumonia include:

  • a cough - this may be a dry cough or you may produce phlegm that is yellow, green, brown or blood-stained
  • a high temperature of 38C (100.4F) or over
  • chest pain
  • difficulty breathing - your breathing may be rapid and shallow and you may feel breathless even when you are resting

If you are being treated for dysphagia and you develop these symptoms, immediately contact your treatment team. If this is not possible, contact your local out-of-hours service or call NHS Direct on 0845 4647.

Symptoms of aspiration pneumonia can range from mild to severe and are usually treated with antibiotics. Severe cases will require hospital admission and treatment with antibiotics through a drip.

Read more about treating pneumonia.

In particularly old or frail people, there is a chance that the infection could lead to their lungs becoming filled with fluid, preventing them from working properly. This is known as acute respiratory distress syndrome (ARDS).

Your chances of developing pneumonia due to dysphagia are higher if you have chronic obstructive pulmonary disease (COPD) or your oral and dental hygiene is poor.

Dysphagia in children

If children with long-term dysphagia are not eating enough, they may not get the essential nutrients they need. This could affect their physical and brain development.

Children who have difficulty eating may also find meal times stressful, which may lead to behavioural problems.

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